Assess on Admission

This is why I do what I do….

Going in to meet my patient for my evening shift, I find her grasping the Nitrous Oxide mask to her face with intensity. Her significant other, rubbing her lower back.

Bedside report was completed and I begin my assessment of her and the equipment in the room. I ask the newly trained Nurse that has so kindly just given me an accurate and complete picture of the last several days of this patients admission if she would like to observe how I assess the position of the infant in utero. I always include, “Where is baby?”, right along side my other routine subjective and objective assessments, unless of course, delivery is imminent.

Her previous Nurse is intrigued and participates, yet I can see the discomfort of her in relation to the fact that she was asked to do something that she maybe she should have done 8 hours ago. She had never been trained in maternal positioning for optimal fetal positioning during her orientation.

The patient was in for an medical induction. She had received 4 doses of

Listen to your heart

I just got off the phone with a pregnant woman. She had left me a message, crying, as she had been told that her baby was occiput posterior and was “a big baby” and that her OB wanted to schedule her for a cesarean section. I typically do not do phone consults, but this time, I couldn’t resist. I called her back; this is what I told her.

1. No one can decide for you as to how you choose to go about your labor and delivery for a non medical reason. Big babies are very hard to determine at full term and we are very often wrong about the estimate. Please see the Evidence Based Birth article on Suspected Big Babies. “Ultrasounds are right about half the time and wrong about half the time when they predict a big baby. Although 1 out of 3 US women are told they have a big baby at the end of pregnancy, only 1 in 10 babies is actually born big.”

2. She was told that she has a high chance of shoulder dystocia. First of all, it is not okay to use scare tactics to get a patient to decide to have a cesarean section. Per EBB, “7 to 15% of big babies have difficulty with the birth of their shoulders, the majority of these cases are handled successfully by the care provider with no harmful consequences to the baby.”

3. Cesarean Sections should be reserved for reasons where every other option for a vaginal delivery has been explored. EBB states, “it would take 3,700 unnecessary Cesareans to prevent one case of permanent injury due to shoulder dystocia.” While I do not look lightly at that one case of permanent damage, let’s look at the risk of a major abdominal surgery for the patient.

4. Please share with your OB and your Doula my Podcast on EBB, February 24th, 2021. Many of these providers admit that they do not know how to handle and promote rotation of an infant in an occiput posterior position. “We were not taught this in medical school.” Today, there are many more infants in this position than ever before, some estimates are that is has doubled in the past 20 years. All I know is that our Cesarean rate is sky rocketing and we need to look at remedies to this crisis now. As proven by my clients and their successful birth stories, malpositioning can Prevented, Identified, and Rotation can be accomplished!

5. Listen to your gut. She wants and believes she can have a safe vaginal birth. She is educated, determined and strong. I support her efforts entirely. I hope she decides to consult with me and that she proves everyone that does not believe in the miracle of birth, wrong.

6. Read all my instagram posts and go to Evidence Based Birth website to get the facts.

The Body Knows

By: Ann Marie Gilligan, Registered Nurse

Hospitals are not only for the sick. It is essential that women receive skilled health care when they give birth. In Tanzania, the rate of maternal and infant mortality is one of the highest in the world. FAME-Africa encourages women, particularly those with a high-risk pregnancy, to get to the hospital for their birth, especially if they do not have access to a skilled birth attendant, even if it may require many hours for their journey.

In my two weeks training the staff at FAME-Africa, I assisted in many births. I was asked to come and facilitate training for the medical team in “Maternal Positioning for Optimal Fetal Positioning.” This is a specialized training that optimizes fetal and maternal well-being by helping the fetus move into the ideal position for birth through a variety of maternal positioning. It is a very safe and straightforward process.

The first step of this process is to view the pregnant mother’s abdomen while she is lying flat on the bed. You get down to the level of the bed and observe which side of the uterus the fetus is leaning towards. Next, you do what is called ‘Leopold’s Maneuver’ to determine where the back of the fetus is in relation to the maternal spine and where the head of the fetus lies in relation to the maternal pelvis. You might then do a sterile vaginal exam to determine the dilatation and location of the fetal head. Based on these observations, you will then instruct the woman, through demonstration and a thorough verbal explanation, which positions she might take to facilitate moving the fetus into a more optimal position: specifically, the fetus’s back on the maternal left.

Studies are consistent in the conclusion that if a fetus is in one of the many less optimal positions at delivery, this alone is associated with a higher risk of adverse neonatal and maternal outcomes. This is why I am passionate about what I do and why I want everyone to learn more about it.

A young primigravida (a woman pregnant for the first time) from the Maasai tribe was admitted to FAME-Africa at 5:00AM in labor. She was examined vaginally prior to my arrival at 8:00AM, and was found to be 2cm dilated and the baby had not yet descended into her pelvis. She reported that she had been laboring for 24 hours. When I met her, she was lying laterally in her bed. Her mother was at her side covering her body with a colorful African cloth and stroking her leg. Each time her uterus would contract, she sang out in a high pitch cry while rapidly slapping her lower back. Her body appeared stiff and rigid in between contractions.

With the help of Tanzanian nurses interpreting for me, I told her that I would very much like to see if I could help rid her of her obvious lower back discomfort. She immediately said yes, and we walked with her to the room in the back of the ward where two delivery beds occupy a room that also serves as a nursery. My Tanzanian RN peer asked permission to touch her body and we viewed her abdomen, then placed our hands on her baby in utero and concluded what position she was in. This little one had somehow decided that the maternal right side was her temporary home while her head was up against the maternal iliac crest (hip bone). If the labor continued with the baby in this position, it could present multiple problems.

Her contractions were palpating strong and were frequent, occurring every three minutes. Our patient was visibly tired and appeared to be in a lot of pain. Our goal was to help the baby get over to the maternal left side, therefore decreasing the discomfort to the woman’s sacrum.

First up was a 5-minute warm shower. The water was aimed frontal and low in the abdomen. This can help relax the muscles and ligaments supporting the uterus. Next, she was instructed on how to do some yoga stretching to bring the respiratory diaphragm off the top of her uterus. The abdominal lift came next to help the infant into a chin flexed position that would enable her to rotate to the other side of the uterus. Our last maneuver is named the “side lying release.” She was assisted into this lateral position in bed and her top leg was brought over and off of the bed. This technique stretches the lower uterine ligaments to make more room for the infant to rotate.

Once her baby was determined to be in the optimal position, I instructed her to get out of bed. I told her to use her voice to help release the intensity of her powerful contractions that were now felt solely in the front of her uterus, near her cervix. She was encouraged to make noise through calm rhythmic breathing and noises that she could call her own. I told her to listen to her body, as it is wise, and will guide her through purposeful movements. Once I gave her this permission and guidance, she became very fluid and danced through her contractions in a way that I have not witnessed in a very long time. She arched her back, swayed her hips, squatted, lifted her arms and waved them in unison. Her voice could be heard throughout the unit and out onto the paved walkways of this open facility. At one point, a male doctor came to check on her and he joined her in dance. We, including the woman, thought this doctor was funny and so we all laughed and danced together.

I encouraged the woman to continue in the upright position, taking short moments to rest when she could, while sitting on the birth ball with her head leaning onto the bed. Food and tea was encouraged throughout her labor. Her mother was always by her side. Sadly, I had a prior engagement that evening as it was my last night at FAME-Africa. I told her she was wonderful, safe, and doing great many times with a hand on her shoulder or holding her hands. The next morning, I did not attend the daily doctors’ meeting and instead looked for the woman so that I could find out the result of her amazing efforts in labor. Isdori, one of the male midwives on staff, had assisted in her birth. I had left at 4:00PM, and she had delivered 2.5 hours after that, at 6:33PM. She had pushed for as little as one hour and her daughter had an Apgar score (a quick method to summarize the health of a newborn) of 9/10.

Mother with newborn at FAME-Africa

I walked into her room, occupied by two other post-partum mothers. She was still shielded by her draped mosquito netting. Her body was turned towards the wall in a fetal position wrapped around her newborn. I called out her name and her face turned towards me. She smiled – a smile that told me, “I did it, I am proud.” Her daughter was nursing and her tiny pink hand was resting on top of her breast. I stroked her forehead and smiled back, telling her she was so strong and brave. Her expression, the one of ultimate self-satisfaction, made my long trip to Karatu, Tanzania all the more worthwhile.

Originally published for Every Mother Counts, March 22, 2019

All In One Evening Shift

I found a note in my phone where I had written abbreviated notes regarding all the women that benefited from maternal positioning in an 8 hour time period during one evening shift of mine. Here they are….will try to put it in non medical terms for all.

Gravida 9 (9th pregnancy). 6cm for several hours. Frustrated. In bed. I encouraged her to get out of bed. All she did was two extended mountain poses (see November 1, instagram) and an abdominal lift (future instagram pic). One hour later, delivery!

G2 (second pregnancy), direct OP (occiput posterior/babe looking at the stars instead of the earth). Deep prolonged decels (decelerations of the fetal heart rate that are 15BPM for longer than two minutes). Infant was at +2 (almost crowning) but there was cervix all around (9cm dilated). Open knee chest with a slight inversion x2 (see instagram from 12/30). Infant rotated with second inversion and delivered OA (occiput anterior), vaginally.

G4, 36 weeks (4th pregnancy), PPROM (preterm premature rupture of membranes before 37 weeks gestation). Not in labor but intense back pain with contractions. Infant was ROT and acynclitic (right occiput anterior and at an angle to left hip) SLR (side lying release) and massage of hips done. Pain gone. Pt was able to sleep the night. Labor started with labor discomfort felt in the front cervical area in the AM, uneventful vaginal delivery.

G3 (3rd pregnancy). Epidural. 6cm for 4 hours. Infant ROA (right occiput anterior), acynclitic (fetal head not in line with birth canal). Extended mountain pose (see November 1 instagram) x2, gluteus maximus and hips massaged. Repeated on other side. Delivery, vaginal, 45 minutes later.

Asked to assist in determining position of fetus on a primigravida (first pregnancy). Second day of Pitocin (synthetic oxytocin) induction. Increased BP. SROM (spontaneous rupture of membranes). Infant ROT (right occiput transverse, acynclitic). I encouraged RN and patient to do maternal positioning to optimize infant position before settling patient in for the second night to decrease chance of longer labor related to malpositioned infant.

Never Give In Until You Say It’s Over

I had met her the evening before. Her primary nurse had wanted assistance with Leopold’s maneuver. This is an assessment that I encourage on every admitted patient on the labor and delivery unit. The conclusion will allow us to determine if she should start doing some maternal positioning right away to help get her infant into the optimal position for birth. At the time of her admission, she presented with a birth plan, her husband and her doula. They were a team on a mission, having discussed her birth plan and how to support her. We were also ready to help her achieve her goal.

22 hours later, as a group of evening nurses stood in our scrubs, we waited to hear which patient we were assigned to. This is always a moment filled with anticipation and excitement, yet a bit of dread for the hard work ahead. I saw her name and heard her story, yet she was not my assigned patient that shift. I was given the title of what we label, “resource nurse.” I had scored! This assignment is always my favorite as I love to assist others; nurses, physicians and our beloved patients. I love going into a room to serve in the role of “second RN,” where my job is to attend to the newborn. How privileged are we to have the job of gently wiping, stimulating, evaluating vital status, weighing, assisting with first feedings, and encouraging the bond between parents and child? I after, all these years, still am in awe of each and every birth.

This above mentioned patient was a woman who was pregnant with her first child, a primigravida. She was ultra fit, a person who had a job where she spent the majority of her word day on her feet, had no underlying pregnancy related diseases, and had an infant who was not measuring large for gestational age. She had reached 10 cm dilitation after 20 hours of labor, and had been pushing for 2 hours when I was asked by her physician to evaluate her current status and report if there is anything I would suggest doing so as she could continue on the path of a vaginal delivery. She was very tired and her nurse had not noticed any descent of the fetal head in the past one hour of pushing.

I went in and calmly discussed who I was and that I had been asked to come in, as I have had special training in what is called maternal positioning for optimal fetal positioning. I asked permission to do a sterile vaginal exam in order to help determine what position the fetal head was in at this time after pushing for two hours on her back. The infant had significant molding to it’s head, yet I could palpate the swelling going horizontal verses vertical. This means that most likely, the infant’s head was transverse. Per my research, more cesarean sections are done for transverse arrest of descent than for any other malposition related to “arrest of descent.” I knew that if this babe was going to be born vaginally, it needed to be given the space to turn it’s head to vertical, may it be occiput posterior of the better choice, occiput anterior (looking down at the floor).

I explained this to the patient and her birth team. I listened to her questions and her insistence that she wanted to continue to try to deliver vaginally. I instructed her and her nurse to stop pushing as of this moment in time. I gave them each a job. First of all, it was important for her to drink some caloric fluids. Who can run a marathon without supplemental energy? Her husbands role was to encourage a sip of fluid every 5-10 minutes. Her doula was to assist me in position changes. Her nurse, having been working hard for the last two hours of pushing, had some charting to do, so I encouraged her to do so.

My immediate goal was to get this little one’s head out of the maternal middle pelvis, enough to allow for a small rotation, so as to decrease the diameter of it’s head, by going in straight verses transverse. Open knee chest was the way in this situation. She had an epidural, so it is always important to determine her ability to get up on her hands and knees. In asking her nurse, she had been able to change lateral positions with very little help throughout this shift. The patient herself felt that she could get up onto her knees with assistance. OK, let’s go! Her doula and I were on either side, one person’s job is to balance her legs, shoulder width apart, her arms supported over a peanut ball at the head of the bed. The other person has her hand under the maternal belly, so as there is never any weight placed on the infant and can adjust the fetal monitoring when needed. Dad was then asked to help support her legs by holding a folded sheet that I had placed through her V shaped body laying across her thighs. He positioned himself at the foot of the bed and helped hold her up, kind of like holding the rope of while water skiing. Slowly, she is positioned into a A shape verses a L shape. It is important that this shape is encouraged as it allows more room due to the front on the pelvis (symphysis) is allowed to open up. She was held in this position for two contractions (or 5 minutes), breathing into her belly with no pushing allowed. Calm relaxing breath, maternal coaching encouraged, instructing her own infant to come out of the pelvis, in order to go back in a more comfortable and safe position. After a few minutes, the doula stated that she felt “a lot of movement.” She was easily returned to her lateral position in bed. I reassessed the infants position via an exam. The head was further up in the pelvis and the swelling was running up and down now! Now it’s time to push!

Lateral pushing is best, as it allows for the sacrum to tilt back to allow for the infant to come into the pelvis, and then once the head is low by the pelvic outlet, it tips forward to allow for the space to open for delivery. After 20 minutes of pushing in the lateral position, her baby girl was born into her waiting arms. Momma was what I call, a “rock star.” I left the room, knowing the beauty and magic of maternal positioning yet again.

Our Actions As Nurses Are Powerful.

Adrienne.

Her name was Adrienne. This was her second pregnancy. Her first child was born vaginally, 15 years ago. I was assigned to her and after a short report, I went in to meet her. Report consisted of her obstetric and medical history. One thing stood out. She was a recovering drug addict that had been clean for two years.

Adrienne was up on her bed, in an all fours position, in active labor, swearing and moving her body frantically. On the couch in the her labor room, were her 2 sisters and her niece, all there to offer their support.

I had been told that she wanted a water birth and did not want any medications for birth. Adrienne had been told wrongly, that she could not get into the tub until it was time to birth. I quickly, reread the hospital policy and checked with my charge RN regarding her request to get into the tub to aid in reducing her discomfort. Adrienne could do what we call “hydrotherapy,” NOW, no waiting for this little one to emerge. I told Adrienne through a calm voice that I was filling the tub and that she could have the labor and birth of her choice.

Once in the tub, her voice calmed, her body was fluid in motion and the room took on a different, powerful yet peaceful ambience. I turned the lights down and Adrienne was what I refer to as, “one with herself.” Oh, mind you, she still swore like a sailor with the contractions, but once it was over, she collapsed into the warmth and security of the warm water and gained strength for the next powerful tightening of her uterus.

I had checked her cervix just prior to her getting into the water. She was 2cm dilated and her baby was still high (meaning not in her pelvis). While waiting for her tub to fill, we did some yoga and stretching standing beside her bed. I gave her family warm blankets and asked for them to be silent as this is what the patient had requested. About 60 minutes into her hydrotherapy, using an air filled glove for a pillow and rocking her hips while elevated by the water, she started making the sounds of wanting to push. I did an exam while she lay back in the water. She was now 8.5cm and 0 station (engaged). I called her provider to no avail. I called my charge nurse and told her I couldn’t get a hold of her provider. I informed Adrienne that her baby was coming and that she would have to get out of the tub, until her doctor arrived. I was able to safely assist her in the delivery of her newborn, but it needed to be in the bed per hospital policy. Just as she was getting out, I heard from her provider that they were on their way. They? Yes, there were a number of physicians that wanted to attend the delivery due to never having seen a water birth. The patient had ok’d this prior, so I did not question the physician. I did stop them at the door and talked to them briefly about what to expect. Adrienne’s personal physician made her way to the side of the tub while the other 5 doctors stayed in the far corner. I called for my second nurse as we do for our deliveries, and she brought her orientee with her. That now made 13 people in the birth room! No one was speaking, no one was making a sound other than the patient and her physician guiding her. It was a beautiful and serene birthing room.

Adrienne delivered her daughter in a way in which she was empowered and in control. She was surrounded by her family and their love. She had the respect of her medical team. All was well, but the best part and what I will always remember was the next part…

Once born, Adrienne stated that she would allow only one person to hold her daughter. I asked who that would be. Outside, there was a fierce storm, and that person had been delayed due to the rain. A few minutes later, a kid walked in. He was tall and beautiful and when Adrienne saw him, tears started streaming down her face. He then looked at her as if to say, “Mom, you did it!” She said through her tears, “here is your sister, you only had to wait 15 years to get one. Son, she is gunna love you!” He came to the bedside and stroked her forehead. I asked if he would like to hold her. Placing her in a warm blanket, she was handed to her big brother. The expression on his face was so incredibly loving…I had to turn my face, so he wouldn’t see me crying.

Several weeks later, I saw Adrienne’s physician in the hallway at work. She thanked me for assisting with Adrienne’s birth. She had just seen Adrienne in the office for her followup visit. She reported that Adrienne was happy and healthy. She was so proud of herself having used no narcotics to get through her labor. I very much believe that it was the water; it’s calming affect and it’s buoyancy, and the ability for her to make her choices known and respected during her delivery that had given her power to fight her addiction.